Nursing Elites

1. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

2. What is a sign of inadequate perfusion?

• A. Intact sensation
• B. Pallor in toes
• C. Bounding pulses
• D. Pink fingers

Correct answer: B

Rationale:

3. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein-rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

4. A nurse is teaching a newly hired group of unlicensed assistive personnel about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?

• A. Properly dispose of contaminated equipment
• B. Perform hand hygiene
• C. Discard used syringes into appropriate containers
• D. Change soiled linens

Correct answer: B

Rationale:

5. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

• A. Avoid contact sports until the infection has cleared
• B. Use a bath sponge to cleanse the skin
• C. Wash hands with soap and water before and after touching the infected area
• D. Use an antibacterial soap when showering

Correct answer: B

Rationale:

Similar Questions